SUMMARY REPORT

July 2014

TORM REPUBLICAN
Occupational accident on 3 December 2013
The Danish Maritime Accident Investigation Board
Carl Jacobsens Vej 29
DK-2500 Valby
Tel. +45 91 37 63 00

E-mail: dmaib@dmaib.dk
Website: www.dmaib.com

Outside office hours, the Danish Maritime Accident Investigation Board can be reached on +45 23 34 23 01.

This marine accident summary report is issued on 10 July 2014

Case number: 2013026421

Front page: TORM REPUBLICAN, mooring lines. Source: DMAIB

The marine accident report is available from the webpage of the Danish Maritime Accident Investi-
gation Board www.dmaib.com.

The Danish Maritime Accident Investigation Board

The Danish Maritime Accident Investigation Board is an independent unit under the Ministry of
Business and Growth that carries out investigations with a view to preventing accidents and pro-
moting initiatives that will enhance safety at sea.

The Danish Maritime Accident Investigation Board is an impartial unit which is, organizationally and
legally, independent of other parties

Purpose
The purpose of the Danish Maritime Accident Investigation Board is to investigate maritime acci-
dents and to make recommendations for improving safety, and it forms part of a collaboration with
similar investigation bodies in other countries. The Danish Maritime Accident Investigation Board
investigates maritime accidents and accidents to seafarers on Danish and Greenlandic merchant
and fishing ships as well as accidents on foreign merchant ships in Danish and Greenlandic wa-
ters.

The investigations of the Danish Maritime Accident Investigation Board procure information about
the actual circumstances of accidents and clarify the sequence of events and reasons leading to
these accidents.

The investigations are carried out separate from the criminal investigation. The criminal and/or lia-
bility aspects of accidents are not considered.

Marine accident reports and summary reports

The Danish Maritime Accident Investigation Board investigates about 140 accidents annually. In
case of very serious accidents, such as deaths and losses, or in case of other special circum-
stances, either a marine accident report or a summary report is published depending on the extent
and complexity of the events.

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Contents
1. PREFACE ................................................................................................................................ 4
2. FACTUAL INFORMATION....................................................................................................... 5
2.1 Photo of the ship ............................................................................................................... 5
2.2 Ship particulars ................................................................................................................. 6
2.3 Voyage particulars ............................................................................................................ 6
2.4 Weather data .................................................................................................................... 6
2.5 Marine casualty or incident information ............................................................................. 6
2.6 Shore authority involvement and emergency response ..................................................... 7
2.7 Scene of the accident ....................................................................................................... 8
3. NARRATIVE ............................................................................................................................ 8
3.1 Background ...................................................................................................................... 8
3.2 Sequence of events .......................................................................................................... 8
3.3 Mooring arrangement...................................................................................................... 12
3.3.1 Mooring setup .......................................................................................................... 12

3.3.2 Snap back zones ..................................................................................................... 13

3.3.3 Procedures and risk assessments ........................................................................... 15

3.3.4 The parted mooring rope ......................................................................................... 15

4. ANALYSIS ............................................................................................................................. 17
4.1 Parting of the mooring line .............................................................................................. 17
4.2 Mooring arrangement and operations ............................................................................. 17
5. CONCLUSIONS .................................................................................................................... 19
6. PREVENTIVE MEASURES TAKEN....................................................................................... 19

Page 3 of 19
1. PREFACE
On 3 December 2013 there was a serious oc-
cupational accident on board the Danish tank-
er TORM REPUBLICAN in Bilbao, Spain.
DMAIBs main focus areas in the investigation
of the accident have been the conflicting goals
that ship crews encounter and negotiate in
their everyday work as well as the interrela-
tions between regulations, procedures, crews
perception of risk and the reality they meet.
This safety report is a summary of these find-
ings.

Page 4 of 19
2. FACTUAL INFORMATION
2.1 Photo of the ship

Figure 1: TORM REPUBLICAN

Photo: Ria Maat/Shipspotting.com

Page 5 of 19
2.2 Ship particulars
Name of vessel: TORM REPUBLICAN
Type of vessel: Chemical/product tanker
Nationality/flag: Danish
Port of registry: Copenhagen
IMO number: 9290658
Call sign: OYNE2
DOC company: Torm A/S
IMO company no. (DOC): 0310062
Year built: 2006
Shipyard/yard number: Hyundai Mipo Dockyard Company Ltd. Ulsan, Korea/0240
Classification society: American Bureau of Shipping
Length overall: 183.2 m
Breadth overall: 32.47 m
Gross tonnage: 29,242
Deadweight: 46,955 t
Draught max.: 12.216 m
Engine rating: 8,580 kW
Service speed: 14.5 knots
Hull material: Steel
Hull design: Double hull

2.3 Voyage particulars

Port of departure: Anchorage off Bilbao, Spain
Port of call: Bilbao, Spain
Type of voyage: Merchant shipping, international
Cargo information: Discharging, Naphtha
Manning: 21
Pilot on board: No
Number of passengers: 0

2.4 Weather data

Wind direction and speed: Southerly, 6 m/s
Wave height: 1.4 m
Visibility: 10 nm
Light/dark: Dark
Current: Unknown

2.5 Marine casualty or incident information

Type of marine casualty/incident: Occupational accident
IMO classification: Serious
Date, time: 3 December 2013 at 0254 LMT
Location: Petronor Terminal Berth 1, Bilbao, Spain
Position: 4322.20 N 00305.67 E
Ships operation, voyage segment: Alongside
Place on board: Main deck
Human factor data: Yes
Consequences: One seafarer injured

Page 6 of 19
2.6 Shore authority involvement and emergency response
Involved parties: Terminal, ambulance/paramedics/doctor, police
Resources used: 2 ambulances, paramedics, doctor, police
Speed of response: 12 minutes (from emergency call to arrival of ambu-
lance)
Actions taken: Injured person brought ashore
Results achieved: Injured person hospitalized for treatment

Page 7 of 19
2.7 Scene of the accident

JETTY NO. 1

LOCATION OF ACCIDENT. ALONGSIDE

PETRONOR TERMINAL, BILBAO, SPAIN

Figure 2: Scene of the accident. Insert: Close-up of terminal

Source: Google Earth

3. NARRATIVE
3.1 Background
The Danish products/chemical tanker TORM
REPUBLICAN was operating in world-wide
tramp trade, i.e. trading on the spot market
without a fixed schedule or ports of call. Dur-
ing the previous year, the ship had called at
33 ports in USA, South and Central America,
the Far East, Europe and Africa. On 25 No-
vember 2013 the ship anchored off Bilbao,
Spain, arriving from Galveston, USA with a
cargo of naphtha. After six days awaiting ac-
cess to the terminal, she weighed anchor on 1
December to approach the port of Bilbao. The
berth was designed for tankers with a
displacement of 25,000-500,000 tonnes and a
LOA 1 of 150-400 m. For vessels of 50,000
DWT 2 and above a minimum of eight mooring
lines at each end was a requirement from the
terminal.
1
LOA: Length overall.
2
DWT: Deadweight tonnage.
At the time of the accident, the crew consisted
of the master, seven officers, one electrician,
one chief cook, one mess man, eight ratings,
one cadet and one ordinary seaman trainee,
21 persons in total.
3.2 Sequence of events
TORM REPUBLICAN took pilot on 1 Decmber
2013 at 0136 hrs. and entered the port of
Bilbao. The ship was moored at Petronor
Terminal, Jetty No. 1 with port side alongside
with a total of 12 mooring lines (figure 3).
The crew received advice on tides, mooring,
swell etc. from the pilot. At the time there was
a wave height of 2.4 metres and the area
generally had significant tides. In addition, the
location of the jetty, on the outermost end of
the breakwater, meant that swell and surges
from passing vessels should be expected, and
as a result extra tension on the mooring lines.
Because of these circumstances, the master

Page 8 of 19
had ordered frequent, at least hourly, tending
to the mooring lines.

Figure 3: Sketch of mooring setup at the time of the accident. The broken spring line is no. 6
Source: DMAIB

Page 9 of 19
At 0254 hrs. on 3 December 2013, the ship
was discharging a cargo of naphtha from two
cargo tanks in the forward part of the ship.
Two crewmembers, an able seaman and an
ordinary seaman trainee, were doing a regular
inspection round on deck checking moorings,
gangway etc. During the round, they took the
opportunity to finish an earlier task of moving
a paint drum from the deck store at the
manifold to the paint store under the
forecastle deck (figure 4). After picking up the
drum, they walked on the port side of the
deck, thus having to pass the forward spring
line and one of the head lines which both led
from the forward starboard mooring winch to
the fairleads at the side. The trainee passed
first underneath both lines, pushing the bucket
in front of him. When he had passed the lines,
he heard some noise, looked back and found
his colleague lying injured on the deck and the
mooring line broken. The able seaman was
severely injured, but conscious. The parted
mooring rope was located some 3 metres
from the railing at the side.

LINE PARTED HERE WALKING ROUTE

SPRING LINES

APPROX. POSITION
WHERE INJURED
CREWMEMBER WAS
FOUND

Figure 4: Bottom: Sketch of main deck seen from above. Crewmembers walking route marked in dashed red
Top: Photo from scene of accident
Source: DMAIB

Page 10 of 19
The duty officer was notified of the accident by
another deck rating who came running to the
cargo control room. The master was informed
and the remaining crew were called for assis-
tance. At 0300 the terminal was informed of
the accident and was requested to call ambu-
lance assistance. A few minutes later the
charterer and the owner were informed. Dis-
charge operations were stopped and the in-
jured man was placed on a stretcher and
moved from the scene of the accident.
Page 11 of 19
An ambulance with paramedics arrived at
0312 and a second ambulance with a doctor
arrived at 0330. At 0354 the patient was trans-
ferred to the jetty and at 0420 the ambulance
left for the hospital.
The local police were on board to inspect the
scene of the accident, and at 0430 the cargo
discharge operation was resumed.
3.3 Mooring arrangement
3.3.1 Mooring setup
The mooring setup of TORM REPUBLICAN
was typical for this type of vessel. On the
raised forecastle deck, there were two
combined anchor and mooring winches, one
in each side. On the aft deck, there were two
mooring winches of the split winch type, and
on the starboard side of the cargo deck there
were two split winches placed just forward of
the accommodation and between the cargo
manifold and the forecastle, respectively. All
winches were hydraulically powered. In
addition to the winches, a number of bollards,
bitts and rollers were installed to
accommodate various mooring scenarios.
Generally the ship moored according to
terminal requirements, often in a configuration
called 2+2+2. This configuration, which was
also used on the day of the accident, meant
that two head lines, two spring lines and two
breast lines at each end were used.
The spring mooring lines shown in figure 3
above (nos. 5 and 6) were led from the
mooring winch placed on the starboard side of
the cargo deck, forward of the manifold area.
Because of the inexpedient match between
the particular jetty and the ship, the forward
spring lines had a very short lead and a steep
angle which is not desireable as it has a
negative effect on the strength and flexibility of
the mooring line (figure 5).

FORWARD SPRING LINE

FROM MAIN DECK

Figure 5: Spring line similar to the parted one. Photo taken on the night of the accident
Source: TORM

The vessel was berthed at the outermost end from passing vessels. During the ships stay at
of the breakwater with very little protection Bilbao, the tide varied approximately 3.5 me-
from the sea and some effect of the waves tres. The combination of these factors meant
was expected, as well as occasional surges that the crew needed to attend to mooring

Page 12 of 19
lines regularly, and thus the master had is-
sued standing orders to this effect.
At the time of the accident, the ship was dis-
charging from two forward cargo oil tanks. The
combined effect of the rising tide and the ves-
sels bow rising due to the discharge caused
increased tension on the spring lines.
PARTED ROPE
Figure 6: Sketch of forward spring mooring arrangement
Source: DMAIB
The mooring setup on TORM REPUBLICAN
was such that the weakest link in case of
overload should be the winch brake (set at
30.6 t) followed by the wire (nominal breaking
strength 55.8 t), the rope tail (nominal
breaking strength 73.5 t) and lastly the fixed
structures such as the winch foundation and
the fairleads. This setup is the standard and is
intended to minimize the consequences in
case of overload. Contrary to the intended
functionality, on the day of the accident the
winch brake was not released and the rope
burst.
The brake holding power of the winches was
checked on a regular basis. For the particular
winch the latest test was carried out on 18
September 2013, confirming the setting of the
brake force at 30.6 tonnes. There were no
company requirements for calibrating the
equipment used for the winch brake holding
tests.
Page 13 of 19
When the ship was moored with the port side
alongside, as it was in this case, the lines
were led across the cargo deck to the port
side fairleads (figure 6). The spring lines
consisted of a 220 metre mooring wire and an
11 metre rope tail attached to it. Normally the
wire part of the line would rest in the fairlead,
but in cases like the present with very short
moorings the rope part was in the fairlead.
FAIRLEADS
ROLLERS
FORWARD SPRING
WINCH
To avoid chafing it was normal procedure to
apply grease to the fairleads. This practice
resulted in the mooring wires and ropes being
soiled.
3.3.2 Snap back zones
When mooring lines break, they will snap back
to the point to which they are fixed, i.e.
winches, bollards, rollers or bitts. Snap back
zones 3 are the areas which constitute the
most likely and therefore dangerous locations
for a person to be in if a mooring line breaks.
Snap back zones are usually painted on the
deck describing an angle, indicating the area
to avoid (figure 7).
3
For detailed information on snap back zones,
rd
refer to OCIMF Mooring Equipment Guidelines, 3
Edition and www.seahealth.dk.
Figure 7: Example of snap back zones
Source: Seahealth.dk
The snap back zones are generally defined
considering the elasticity of the lines used, the
angles and leads which are commonly used
on board and the predominant expected
behaviour of a parting mooring line. The
possible area of the snap back zone of the
rope when it recoils will increase in breadth
Page 14 of 19
the further it travels from the point of
breakage. The end of the broken rope may
also recoil past the point to which it is secured
to a distance almost equal to the remaining
length. A mooring line which is leading around
a pedestal roller will whip back in a wide arc
as it returns to the point to which it is secured.
TORM REPUBLICAN had snap back zones
marked on the deck. In the area where the
accident happened, no zones were marked on
Figure 8: Snap back zones at starboard side forward, TORM REPUBLICAN
Source: DMAIB
3.3.3 Procedures and risk assessments
Among the tools available to the ships crew
was a shipboard manual which contained a
section on safe mooring operations. The ship-
board manual is a generic document and is
not made specifically for the individual vessel.
The main areas that the manual describes are
types of mooring operations, familiarization,
lists of factors to consider, the use of shack-
les, mooring management and general safety
reminders. Examples of the latter include:
Always stand well clear of a mooring line un-
der load., ... synthetic fibre ropes give little or
no warning when it is about to break ...
A risk assessment was also available on
board, containing a selection of identified risks
and their countermeasures which were to be
considered in connection with mooring opera-
tions. Among the items dealt with in the risk
assessments were: Fatigue, lack of compe-
tency, running of wires, rotating machinery,
manual handling and poor communication.
As per company procedures, mooring lines
were used for a maximum of 18 months after
which they were replaced. The parted mooring
Page 15 of 19
the deck. Figure 8 shows the snap back zones
at the similar position in the starboard side.
rope tail had been brought into service on 24
August 2012 and thus was due for replace-
ment in approximately 3 months.
3.3.4 The parted mooring rope
The parted rope tail was an 8-strand nylon
rope, 64 mm in diameter and 11 metres long,
with covered (chafe protected) eye splices at
both ends. When new, the rope had a
minimum breaking strength of 162,000 lbs
(approx. 73.5 tonnes).
This type of rope has an indicator strand
woven into it over the full length of the rope.
The indicator strand will break when the rope
is subjected to elongation in excess of 30%.
Examination of the parted rope tail revealed
the following:
- The rope tail burst as a result of over-
load. Most cords showed signs of
breaking due to overload (figure 9).
- The breaking strength of the rope may
have been reduced by as much as
 30% due to wear (chafing). Many
strands and cords showed general
signs of wear and chafing, especially
around the location of the break (figure
10).
- While the use of grease on ropes in it-
self probably did not reduce the
strength, the grease did make it diffi-
cult to establish the condition of the
mooring ropes.
SOME STRANDS SHOW
SIGNS OF BREAKING DUE TO
WEAR.
Figure 9: Details of the parted rope end
Source: DMAIB
Page 16 of 19
- The indicator string was broken and
fragmented along the full length of the
rope, indicating that at some point in
time the rope had been subjected to
elongation in excess of 30%. In its
original, undamaged condition this
type of rope can withstand elongation
of approximately 50% before breaking.
It was not possible to establish wheth-
er the elongation happened just prior
to the rope parting or on an earlier oc-
casion.
BROKEN STRANDS HAVE VARYING
LENGTH. FIBRES SHOW SIGNS OF
BREAKING DUE TO OVERLOAD.
 BROKEN OUTER STRANDS AND
FIBRES. SEVERE ABRASIONS
PROBABLY RESULT OF CHAFING.
Figure10: Details of parted rope. Both pictures show discolouration from grease
Source: DMAIB
4. ANALYSIS
The accident occurred when a crewmember
passed beneath a mooring line just as it
broke. In analysing the accident, focus will be
on two main items; the parting of the rope and
the general mooring operation and the proce-
dures leading up to the occurrence.
4.1 Parting of the mooring line
It was established that the rope end parted as
a result of overload and that the winch brake
did not release before the rope broke. The
possible explanations for this are:
- The brake setting may have deviated
from the expected. The brake holding
power of the winch was tested and
adjusted using an uncalibrated
instrument.
- The breaking strength of the rope was
reduced due to abrasions from chafing
and a previous elongation which had
caused permanent deformation.
Page 17 of 19
SIGNS OF INTERNAL WEAR: SOME
FIBRES/YARNS WERE MELTED OR
APPEAR FLUFFY.
- A combination of both.
- Also contributing to the parting of the
rope was the tide, the cargo discharge
from the forward tanks and the inex-
pedient short lead and steep angle of
the spring line.
4.2 Mooring arrangement and
operations
When analyzing the accidental events on
TORM REPUBLICAN, it can in hindsight be
argued that the crewmembers should have
recognized the danger of passing underneath
a mooring line under tension. The question of
why they chose to pass the mooring line must
be understood with the crewmembers
viewpoint in mind.
On the day of the accident, they had the task
of doing an hourly round to inspect and tend
to the moorings, and the job of moving a paint
drum forward. In an optimization process
these two tasks were not seperated and the
tasks were completed in what was thought of
as a meaningful and low risk manner. They
could have chosen an alternative route from
the deck store to the paint store which would
not bring them close to the line, but then they
needed to go back to tend to the mooring
lines. As the deck hands were handling
mooring lines on a daily basis, it was not
considered dangerous to be near them.
Further, the mooring rope spanned from one
side of the ship to the other offering little room
for the crew to pass them without being in a
snap back zone depending on where the rope
would break.
The shipboard manual and risk assessments
did list a number of factors and risks to con-
sider in connection with mooring operations,
but the task of tending and checking moorings
was not dealt with in detail. For instance, nei-
ther the manual nor the risk assessments
suggest how to tend to moorings without posi-
tioning oneself in a dangerous situation or ar-
ea. A number of normative terms are used,
such as always stand well clear of a mooring
wire under load, proper and correct mainte-
nance and good, seamanlike line tending.
The practical use of such terms is probably
limited in an everyday working situation.
Common to many such procedures is that,
although taken individually they offer sound
advice, procedures cannot cover every possi-
ble situation and are often contradictory, for
example, the combination of crewmembers
being told to a) Always stay clear of lines un-
der tension and b) Tend to all mooring lines at
least once an hour.
The other identified hazards listed in the risk
assessments such as fatigue, lack of compe-
tence, poor communication etc. are real haz-
ards to be dealt with. However, the control
measures to be implemented do not neces-
sarily address the underlying problems. For
example, in the risk assessment the control
measure to counter fatigue is: Officers to en-
sure that they are as well rested as possible
prior to port operations. Chief Officer to en-
sure that crew members are likewise rested. 4
Issues that are not addressed in detail are
how the crew should ensure that they are well
4
Quote from Risk Assessment MEG3 Effective
Mooring
Page 18 of 19
rested and what they should do if they do not
feel up for the task?
Snap back zones might offer some valuable
assistance in establishing safe and unsafe
areas on deck. However, unless a vessel has
a very fixed system of mooring, for instance
ships repeatedly calling at the same ports all
the time, the establishment and marking of
possible snap back zones can easily lead to
more confusion than clarification. Another
problem with marking unsafe areas is the risk
that all other areas are then considered safe,
which is not necessarily the case. When
mooring lines break, it is not possible to pre-
dict exactly which way they will travel and thus
no area near moorings can be considered
completely safe.
Another factor that may contribute to this type
of accident is the rather strict mooring re-
quirements and guidelines set by terminals.
This could create a tendency to weigh compli-
ance higher than safety issues when selecting
the mooring setup. In this instance the re-
quirement from the terminal was to deploy six
mooring lines at each end. This may have re-
sulted in the decision to use the two forward
spring lines despite the fact that it was known
they would have short leads and steep angles.
While, on the one hand, the ports require-
ments and guidelines can be both reasonable
and helpful, on the other hand, they could also
restrict the master and crew in their decision
making. One example is the prohibition of us-
ing constant tension winches which is wide-
spread in oil terminals. Although not neces-
sarily the solution to all mooring problems,
constant tension winches may have been able
to prevent some accidents in the past. These
are general issues and not particular to this
accident.
5. CONCLUSIONS
The accident on TORM REPUBLICAN
occurred as a result of multiple coinciding
factors:The layout of terminal/jetty vs ship size
and layout, a mooring line which had a
reduced breaking strength, and the
unfortunate coincidence that the rope parted
just as the crewmembers were passing
beneath while doing normal maintenence
work.
Common to many mooring accidents is that
they happen under normal circumstances and
are not exclusively due to some extraordinary
outside influence or human action or
omission. Mooring operations are routine jobs
which are carried out by the crew on a regular
basis and are therefore not considered to
expose them to an immediate hazard. Since
all work contains an element of risk, it will
always be carried out as a result of a
negotiation of two different goals: Getting the
job done, and being safe. Understanding this
negotiation is essential for creating safety.
6. PREVENTIVE MEASURES
TAKEN
Following the accident the company carried
out an internal investigation. Among the pre-
ventive measures taken are:
- A detailed Safety Flash and safe
mooring guidelines were sent to all
fleet vessels.
- On-board debriefing on safety proce-
dures and awareness carried out by
Safety superintendent and Head of
SQE.
- The vessel was to conduct an extraor-
dinary safety meeting regarding the in-
cident, with emphasis on mooring pro-
cedures and safety.
- A follow-up extraordinary internal ISM
audit to be carried out on the vessel to
review safety procedures and aware-
ness.
Page 19 of 19
Mooring arrangements are sometimes
designed in such a way that they become
inherently dangerous, which will challenge the
way crews operate despite the efforts made to
develop safe mooring practices. Great forces
are present: Winches, mooring lines and wires
under tension, people physically operating
very close to these forces with limited visibility,
time constraints and very little room to
operate. Because of the complexity of
mooring arrangements and operations and
due to the designs that are sometimes
inherently dangerous, it is difficult for the
crewmembers to predict where the safe areas
are, if there are indeed any safe areas. The
design of the mooring arrangements makes it
very difficult for crews to operate safely as
they have no other option than to be
physically very close to the equipment, thus
repeatedly putting themselves in danger.
- Ships mooring winch brakes to be re-
tested to check if settings are correct.
- Incident findings to be shared with en-
tire fleet.
- Safe mooring procedures in QMS to
be amended to highlight risks associ-
ated with short mooring lines, unsuita-
bly placed bollards and movement of
vessel causing chafing of mooring
lines.